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So you think you know how to measure and assess posture?

*notes: I don’t like the title ha, it sounds a bitty conceited but it did make you click and I figured it would be more interesting then “a thorough examination of the reliability of the visual assessment of the lumbar spine”. Anyways I think there is a valuable message here in examining the reliability of any practice you do as a trainer. Enjoy!

Justin

Posture; I haven’t talked about this subject in quite some time, frankly I’ve been spending more time focusing on learning more about strength training and programming. However, just because I haven’t really talked about it doesn’t mean I still haven’t been reading the research on it. In fact, Dr. Jonathan Fass and I are hopefully in the end phases of a research review on whether or not personal trainers should assess lumbar posture so it’s safe to say I’ve read a large percent of the relevant research on the subject.

Here’s the thing, I’m still noticing a lot of trainers talking about posture, specifically the alignment of the lumbar spine and its relationship to the pelvis (anterior pelvic tilt or posterior pelvic tilt). For simplicities sake let’s ignore the claims which include the alleged association between postural deviation and muscle imbalances and its association with pain and just focus on one question; as a personal trainer, do you really know how to assess lumbar posture? This means its accurate measurement and its change over time.

Let’s phrase this another way; your client wants to get stronger. You have a pretty good idea on how to measure a client’s strength. You might use the bench press or pull up for upper body strength or a leg press or squat for lower body strength. Now these are by no means gold standards for measuring strength but if a client can move more weight over time they have likely gotten stronger. So you have your assessment (leg press, squat, bench press, or whatever you decide to use) and you have your intervention which would be your training program. If your client gets stronger and they weren’t doing any training other than what you prescribed then your training program probably was the variable that changed their strength levels.

So you have your measure of strength which can be quantified by an actual number and your intervention which you predict will change the originally measured number. Now imagine how illogical it would be to say that you have a program that increases strength when you have no idea how to measure strength.

So before continuing to read ask yourself two questions (1) do you assess lumbar posture? And (2) do you know how lumbar posture is measured?

What is lumbar lordosis?

Lumbar lordosis refers to the anterior or inward curvature of the spine (Been).

How is lordosis measured and what is considered normal?

The problem with comparing data is that there are so many different ways people have measured lumbar lordosis. If you’re really interested check out this review by Vrtovec and colleagues. From what I’ve read, the Cobb method seems to be the standard. Cobbs method forms an angle by drawing a line at the superior endplate of L1 as well as a line at the superior endplate of the sacrum.

Cobb angle

So what’s normal?

This table comes from Roussouly, Gollogly, Berthonnaud, and Dimnet. They found that the average value for lordosis was 61.4 degrees with a range of 41.2 degrees to 81.9 degrees with the number of vertebrae contributing to the lordosis being between one and eight. They also identified four different classifications of lordosis.

Type 1 Type 2 Type 3 Type 4
Sacral slope Less than 35 degrees Less than 35 degrees Between 35 and 45 degrees Greater than 45 degrees
Lordosis range 41-64 degrees 44-58 degrees 43-76 degrees 61-82 degrees
Number of lordotic vertebrae 1.5-6 4-7.5 3-6.5 3.5-6
Prevalence 34 subjects 18 subjects 60 subjects 48 subjects

Type 3 is considered a well aligned spine but none of the individuals in this study, despite the wide range had back pain complaints.

Furthermore, Lin and colleagues also measured lumbar lordosis in a sample size of 149 subjects. The researchers discovered that the mean lordotic angle of this sample was 33.2 degrees. With one standard deviation, normal lordotic curve was 20-45 degrees. Lastly, Murrie and colleagues generated a modified Cobb angle by measuring the angle created from a line drawn between the L1/2 and L5/S1 disc spaces. The measured lordosis covered a wide range of 20 to 80 degrees.

I don’t remember the exact study but in the review section a researcher was quoted (okay I’m totally paraphrasing) as saying there is no point in defining normal spinal curvature due to large variations within the population.

Can it be accurately measured?

The answer is yes, lumbar lordosis can be accurately measured. Unfortunately just not by those still conducting visual assessments (which to my knowledge is the only way I’ve seen trainers do it). According to Vrtovec, Perus, and Likar examination of spinal curvature becomes more accurate when the evaluation is completely automated meaning relative to computerized evaluation, visual inspection is considered to be subjective, unreliable, and inconsistent (Vrtovec).

In fact there are several variables that might confound your visual analysis including gluteal prominence and stomach size. In a presentation I did this summer on the subject I had three pictures, two of them were of me and one was of another person. In one of the pictures of me I padded my butt with a towel to make it look bigger. I asked the people in the audience to rate who had a larger lordosis. The padded picture of me was rated as having a greater lumbar lordosis than the non padded picture. For example in this study by Mosner and colleagues titled,a comparision of actual and apparent lumbar lordosis in black and white adult females, they found that gluteal prominence played a role in how investigators perceived the size of a persons lumbar lordosis.

The reliability of visual inspection doesn’t get better from there but I urge you to figure this out for yourself by reading this (if you need the pdfs I can get them for you just message me or email me Justin.kompf90@gmail.com).

http://www.ncbi.nlm.nih.gov/pubmed/18796885

http://www.ncbi.nlm.nih.gov/pubmed/12923476

Here’s the bottom line, there are a wide variety of spinal curves that are all nonpathological and thus considered ‘normal’ although the fact that there are so many acceptable values makes the term normal basically useless. Next, research does not support the use of the visual assessment for posture. I’m going to list over 40 references below on lumbar lordosis, its measurement, association with pain, and muscle imbalances. If you’re a personal trainer and still evaluate spinal curvature I strongly urge (no insist) that you at least read some of these references from each category to evaluate your practice. I will be happy to supply pdfs if any readers want them.

Finally, don’t take this the wrong way. I am not saying lumbar posture is totally irrelevant. Some postures may be aesthetically unappealing to the person with said posture and some postures have been associated with pain (read Adams reference) although the evidence is not in favor of that claim. All I am saying here is that if you want to continue assessing lumbar posture please find a way to do it reliably.

Adams MA, Mannion AF, Dolan P. Personal risk factors for first time low back pain. Spine 24: 2497-2505, 1999.

Balague F, Mannion AF, Pellise F, and Cedraschi C. Non-specific low back pain. The Lancet 379: 482-491, 2012.

Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. Anthropometric and clinical measures as predictors of back pain complaints in industry: A prospective study. J Spinal Disord 3: 195-204, 1990.

Been E and Kalichman L. Lumbar lordosis. Spine J 14: 87-97, 2014.

Britnell Sj, Cole JV, Isherwood L, Sran MM, Burgi S, Cardido G, and Watson L. Postural health in women: The role of physiotherapy. J Obstet Gynaecol Can 27: 493-510, 2005

Bryan JM, Mosner E, Shippee R, and Stull MA. Investigation of the validity of postural evaluation skills in assessing lumbar lordosis using photographs of clothed subjects. J Orthop Sports Phys Ther 12: 24-29, 1990.

Chaleat-Valayer E, Mac-Thiong JM, Paquet J, Berthonnaud E, Siani F, and Roussouly P. Sagittal spino-pelvic alignment in chronic low back pain. Eur Spine J 20: 634-640, 2011.

Christensen ST, Hartvigsen J. Spinal curves and health: A systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther 9: 690-714, 2008.

Christie HJ, Kumar S, Warren SA. Postural aberrations in low back pain. Arch Phys Med Rehabil 76: 218-224, 1995.

Clark M, Lucett S, and Sutton BG. NASM Essentials of Corrective Exercise Training. Philadelphia, PA: 2011.

Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8: 8-20, 2008.

Deyo RA, Mirza SK, and Martin BI. Back pain prevalence and visit rates: Estimates from U.S. national surveys, 2002. Spine 31: 2724-2727, 2006.

Dunk NM, Lalonde J, and Callaghan JP. Implications for the use of the postural analysis as a clinical diagnostic tool: Reliability of quantifying upright standing spinal postures from photographic images. J Manipulative Physol Ther 28: 386-392, 2005.

During J, Goudfrooij H, Keessen W, Beeker TW, and Crowe A. Towards standards for posture. Postural characteristics of the lower back system in normal and pathological conditions. Spine 10: 83-87, 1985.

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  2. Fedorak C, Ashworth N, Marshall J, and Paull H. Reliability of the visual assessment of cervical and lumbar lordosis: How good are we? Spine 28: 1857-1859, 2003.
  3. Hansson T, Bigos S, Beecher P, and Wortley M. The lumbar lordosis in acute and chronic low-back pain. Spine 10: 154-155, 1985.
  4. Hayden JA, van Tulder MW, Malmivaara AV and Koes BW. Meta-Analysis: Exercise therapy for nonspecific low back pain. Ann Intern Med 142: 765-775, 2005.
  5. Heino JG, Godges JJ, and Carter CL. Relationship between hip extension range of motion and postural alignment. JOSPT 12: 243-247, 1990.
  6. Herrington L. Assessment of the degree of pelvic tilt within a normal asymptomatic population. Man Ther 16: 646-648, 2011.
  7. Kendall FP, McCreary EK, Provance P. Muscle Testing and Function. 4th ed. Baltimore, Md: Lippincot Williams & Wilkins; 1993.
  8. Kim HJ, Chung S, Kim S, Shin H, Lee J, Kim S, and Song MY. Influences of trunk muscles on lumbar lordosis and sacral angle. Eur Spine J 15: 409-414, 2006.
  9. Kritz MF and Cronin J. Static posture assessment screen of athletes: Benefits and considerations. Strength Cond J 30: 18-27, 2008.
  10. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. J Bodyw Mov Ther 15: 131-138, 2011.
  11. Levine D, Walker JR, and Tillman LJ. The effect of abdominal muscle strengthening on pelvic tilt and lumbar lordosis. Physiother. Theory Pract. 13: 217-226, 1997.
  12. Li Y, McClure PW, and Pratt N. The effect of hamstring muscle stretching on standing posture and on lumbar and hip motions during forward bending. Phys Ther 76: 836-845, 1996.
  13. Lin RM, Jou IM, Yu CY. Lumbar lordosis: Normal adults. J Formos Med Assoc 91: 329-333, 1992.
  14. Melzack R, Katz J. Pain. WIREs Cogn Sci 4: 1–15, 2013.
  15. Moreside JM and McGill SM. Quantifying normal 3D hip ROM in healthy young adults males with clinical and laboratory tools: Hip mobility restrictions appear to be plane-specific. Clin Biomech 26: 824-829, 2011.
  16. Mosner EA, Bryan JM, Stull MA, and Shippee R. A comparison of actual and apparent lumbar lordosis in black and white adult females. Spine. 14: 310-314, 1989
  17. Murrie VL, Dixon AK, Hollingworth W, Wilson, Doyle TA. Lumber lordosis: Study of patients with and without low back pain. Clin Anata 16: 144-147, 2003.
  18. Norton BJ, Sahrmann SA, and Van Dillen LR. Differences in measurements of lumbar curvature related to gender and low back pain. J Ortho Sports Phys Ther 34: 524-534, 2004.
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  22. Rinkus KM, and Knaub MA. Clinical and diagnostic evaluation of low back pain. Seminars in Spine Surgery 20: 93-101, 2008.
  23. Ronai P and Sorace P. Chronic nonspecific low back pain and exercise. Strength Cond J 35: 29-32, 2013.
  24. Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30 346-353, 2005.
  25. Scannell JP,and McGill SM. Lumbar posture-should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living. Phys Ther 83: 907-917, 2003.
  26. Toppenberg RM and Bullock MI. The interrelation of spinal curves, pelvic tilt and muscle lengths in adolescent females. Aust J Physiother. 32: 6-12, 1986.
  27. Tuzun C, Yorulmaz I, Cindas A, and Vantan S. Low back pain and posture. Clin Rheumatol 18: 308-312, 1999.
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  29. Walker ML, Rothstein JM, Finucane SD and Lamb RL. Relationship between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther 67: 512-516, 1987.
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  31. Youdas JM, Garrett TR, Harmsen S, Suman VJ, Carey JR. Lumbar lordosis and pelvic inclination of asymptomatic adults. Phys Ther 76: 1066-1081, 1996.
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How bigger glutes may improve the squat and deadlift

“Strength is a product of muscular action initiated and orchestrated by electrical processes in the nervous system of the body. Classically, strength is defined as the ability of a given muscle or group of muscles to generate muscular force under specific conditions.” (Verkhoshansky 1)

– Verkhoshansky and Siff

 

There are so many factors that contribute to how a person expresses strength. Some factors cannot be changed, such as limb length. For example, short arms would be beneficial for the bench press but not the deadlift (Keogh). Other factors can be controlled such as muscle hypertrophy and more effective nervous system stimulation.

 

Several months ago I was at the Fitness Summit in Kansas City. Bret Contreras, one of the speakers had a presentation entitled “Contributing Factors to Displays of Strength”. In one of his slides he covered how gluteal hypertrophy can lead to increased hip extension torque. He stated that, “increasing gluteus maximus hypertrophy by 32% leads to 50% increase in torque potential”. As a competitive powerlifter, anything to do with increasing strength peaks my interest so I decided to dig deeper into the biomechanical rational behind that statement. This article is going to examine why increased gluteal hypertrophy may help to increase torque (strength) in the squat and deadlift. First here’s what you need to know: (more…)


Is there a most important training aspect to increase muscle size?

A common training goal is to improve body composition, meaning lose fat gain muscle. Beginners to resistance training usually see rapid gains in strength and then subsequent gains in muscle growth. However, as a people advance continually increasing muscle size may be difficult. The best mechanism for hypertrophy has been debated and researched. It is generally accepted that muscle tension, metabolic stress, and muscle damage are the cause of muscle growth but it is unknown whether causing more than one of these scenarios is additive or redundant (3). Simply stated, is muscle tension + metabolic stress better than muscle tension or metabolic stress on its own?

arnold-pump

(more…)


Why does training with bands and chains work?

Powerlifters have been using variable resistance training with bands and chains for some time now. Variable resistance training has been shown to increase strength, power, and rate of force development of users (Joy). With variable resistance training external load changes throughout the range of motion (McMaster).

get it.. ha … ha

In order to understand why variable resistance training works it is important to understand strength curves. Multijoint strength curves for exercises such as the squat and deadlift are calculated by adding the torques of all the joints in the exercise. Strength curves can be ascending where max strength and force capabilities peak at towards the end of the lift (squat, deadlift, bench press), they can be descending where maximum strength occurs at the beginning of the lift (pull-up, chin-up) or they can be bell shaped (biceps curl) where maximal strength producing capabilities occur in the middle of the lift (McMaster). You’re going to have to look closely to see the image below demonstrating strength curves.

With bands and chains the resistance is greatest at the top of the movement. Since powerlifting movements like the squat, deadlift, and bench press have ascending strength curves where maximal force production occurs near the end of the lift, the added resistance matches the strength curve and may maximize strength gains (McMaster). (more…)


An examination of energy expenditure when squatting for reps

 

If you’ve squatted for reps you probably know that you’ve just done a cardiovascular workout especially as the weight increases. A ten rep squat at 300lbs would leave me gasping for breath with my heart rate through the roof, I have long femurs so the bar has to travel quite far for me to hit parallel ( exaggerating a little on the gasping but you get the point).  Just the other day I completed a pyramid loading squat routine which we’ll examine later in this article.

*Cory confirmed for wearing sunglasses in doors

What you need to know

  • Resistance training places demands on the phosphagen, glycolytic, and mitochondrial energy systems (Robergs) and can certainly be used in conjunction with diet interventions to help aid in fat loss and favorable changes in body composition
  • Could it also help with cardiovascular function? Escamilla et. al stated that deadlifting for 4 sets of 8 at 175 kg would have the lifter expending 3.5 L *O2/min -1 which is relatively high compared with walking, jogging, and other common actives (Escamilla). You can read more about that here.

(more…)


How Hormones Effect Your Workout

Chapter 3: Endocrine Responses to Resistance Exercise

 

strong121

Photo Source: http://www.unchainedfitness.com/wordpress/wp-content/uploads/2012/12/strong121.jpg

The endocrine system is an important part of keeping our bodies in balance, also called homeostasis.  This system controls glands such as the adrenals which secrete hormones which are chemical messengers in our bodies.  These hormones communicate with specific cells via receptors coded only to that hormone, in this way targeted tissues can be affected rather than the entire body.  In this way the endocrine system can have much more precise control over regulating body functions.  The nervous system and endocrine system are closely linked, (more…)


50:10 Finisher Workout

Here is a short finisher style workout I did after leg day, it can be used on its own as well if you are short on time.  Get warmed up then be ready for non stop movement, you never rest more than 10 seconds for the entire 16 minutes.  Do 50 seconds of as many reps as you can of an exercise then rest 10 seconds, then start with the next exercise on your list, get through all four exercises this way and then start over.  Unlike most circuits, you do not get extra rest at the end of each circuit.  This keeps the workout short, which is nice but it makes it very tough, give it a shot and see how many reps you can get.

(more…)


The Road Less Traveled To Fat Loss

coverYou don’t necessarily have to make your program the way most people do, with sets and reps and standard exercises.  You can get into great shape through activities too, look at all the possibilities that exist especially since summer is coming.  Get out on the water with some kayaking, on the beach with some volleyball or out on the trails for some mountain biking.  Looked at another way, taking up an activity like this may be exactly what you need to get yourself motivated to train again… (more…)


Comparing Calisthenics And Gymnastics

coverBoth of these methods use the human body itself along with gravity to create resistance, but they are not the same.  How are they the same and how are they different?  How will training one carry over to the other and what about carry over to other activities?  These are the ideas I discuss in this video. (more…)


Quick Elbow Lever Tutorial

Impress your friends with this simple bodyweight trick!  If you have never tried this, you might think it is harder than it is.  This movement is really just about flexibility and balance and it is pretty fun once you figure it out.  This is a very short video on how to do it, if you need more instruction there are a ton of guys on youtube who can teach you but this may be all you need, I didn’t get much more instruction than this and I figured it out after a few tries last fall.  Give it a shot and see what you can do!